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The migration of health workers and pharmacists in particular is seen as a problem with no easy solution. It is not simply a matter of difference in salary, but also in training and career progression opportunities and a conducive practice environment. A comprehensive package which offers a range of incentives is the best way forward.

2006 World Health Day in Zambia

Tana Wuliji reports.

The migration of health workers has many catchy labels – some call it brain drain, others call it brain gain or even brain circulation, but for Ruth* – a final year pharmacy student from Zimbabwe – migrating abroad is a life changing decision which is not taken lightly. Over the past ten years, the migration of pharmacists to countries such as the UK, Australia and Ireland has increased. Half of all final year pharmacy students like Ruth, surveyed across nine countries worldwide including Nepal, Bangladesh and Zimbabwe, planned to migrate within five years. More than half of these planned to remain abroad long term.

Such figures are perhaps not surprising, but may be a cause for concern for any country which invests in the development of its own health workforce. In order for policies to be effective in maximising the gains and minimising the risks from migration, there is a need to take the underlying factors influencing migration intentions into account. In the case of pharmacists, it seems to be as much a reflection of the individual’s perception of the home environment as it is of the perception of opportunities abroad.

It is tempting to simplify the problem of migration to a matter of differences in salaries between countries. However, retaining health workers requires a more holistic understanding of the factors that influence migration intentions.

Ruth’s perception of opportunities to develop her career and financial situation abroad are just one set of factors she will take into consideration. The issue of salaries cannot be separated from professional development and both need to be addressed. For example in Australia, the rural workforce recruitment and retention programme offers packages to offset disincentives for working in remote and rural areas, like offering allowances and supporting continuing education. As a result, over the last six years, the number of pharmacists in the rural community has grown by 12 per cent.

However, salary and career are not the only considerations. Ruth’s attitudes towards the local practice and professional environment, and social and political environment will also shape her migration intentions. The latter may be outside the health sector’s zone of influence.

Those who plan to migrate long term also have negative perceptions of the professional status and practice environment within their home countries compared to those that do not plan to migrate. To ensure job satisfaction, Ruth needs to feel that her services are valued by her colleagues, members of other health care professions and patients. The work environment should also be felt to be conducive for her performance, with policies that support the services that she will provide.

Interestingly, an average of 20 per cent of final year pharmacy students plan to migrate on a short term basis. There is no difference in the attitudes of these students compared to those that do not wish to migrate at all; both view the home environment positively, in contrast to those planning long term migration. This means that it is very important to know the difference between those who plan to migrate on a short term basis and those planning to migrate on a long term basis as these groups have completely different attitudes and perspectives. Short term migrants are more likely to return home, hold positive perceptions about their home environment and facilitate mutual gains from migration abroad. Those planning long term migration will be the most difficult group to retain and least likely to return from abroad.

In packing away the labels for migration which oversimplify a complex issue, strategies that aim to retain pharmacists like Ruth are more likely to be successful with a comprehensive package of interventions that satisfy her needs. In addressing the underlying factors that influence migration, retention across the health system can be improved; the very same factors not only shape the movement of health workers between countries, but within as well.

Lay or community workers can be a valuable resource in response to the human resource crisis in many low- and middle-income countries. Successful interventions by lay health workers have led to improvements in maternal and child health, including reductions in mortality and morbidity from common childhood illnesses, and effective support to people receiving treatment for tuberculosis.

Simon Lewin and Claire Glenton of the LAYVAC (Lay health workers for vaccination) Project Group give more of the story.

Thirty years after the Alma-Ata Declaration, the World Health Organization (WHO) and a wide range of other agencies are calling for the revitalisation and reinvigoration of the primary health care approach. A key component of primary health care as envisaged at Alma-Ata is the lay or community health worker (LHW). The 1970s saw the rapid expansion of many LHW programmes in low- and middle-income settings. For example, the Auxiliares de Medicina Simplificada (Simplified Medicine Auxiliaries) programme in Venezuela trained thousands of LHWs, or “little doctors” as they are known locally, to provide health services to indigenous groups and isolated communities across the country. Recruited from the communities they serve, and skilled in primary health care, this cadre are still respected locally for their medical proficiency.

In Nepal, the Female Community Health Volunteer (FCHV) Programme, established by the government in 1988, now has more than 48,000 trained women who spend on average five to six hours a week on activities tied primarily to maternal and child health. The FCHVs are trained to deliver a number of key interventions, including the distribution of vitamin A supplements and oral rehydration salts; antenatal care; participation in vaccination campaigns; and, in some cases, the diagnosis and treatment of childhood pneumonia. The programme is generally seen as a key contributor to the decrease that Nepal has achieved in childhood mortality and morbidity over the last two decades.

Across a wide range of settings in both the North and the South, LHWs perform diverse functions related to health care delivery. The term ‘lay health worker’ is broad in scope and includes, for example, community health workers, village health workers, health promoters, treatment supporters and birth attendants. While LHWs are usually provided with informal job-related training, they have no formal professional or para-professional tertiary education and can be involved in either paid work, as in the Venezuelan programme, or voluntary care, as in the Nepalese FCHV system.

The renewed interest in LHWs has been prompted by a number of factors. These include the human resource crisis in the health care systems of many low- and middle-income countries; the AIDS epidemic; the resurgence of other infectious diseases such as tuberculosis (TB); and the difficulties faced by the formal health system in providing adequate care for people with chronic illnesses. An increasing emphasis on partnership with community-based organisations and consumer involvement in health care has also contributed to this renewed interest in some settings.

It has been suggested widely that LHWs may play an important role in extending services to ‘hard to reach’ groups and in substituting for health professionals in a range of tasks, thereby helping to achieve the Millennium Development Goals for health.

This interest in LHW programmes has also revived questions regarding the effectiveness and cost of such programmes. Before scaling up these interventions, policy makers need evidence that they do more good than harm.

Evidence on the effectiveness of LHW interventions is developing rapidly. A global review of best evidence in this area, undertaken as part of a Norwegian Research Council funded study of LHW programmes (see http://sintef.org/Teknologi-og-samfunn/global-helse/Helsetjenester/LayVac/), identified a number of important messages. The review shows that the use of LHWs in maternal and child health programmes can have promising benefits across a range of outcomes, compared to usual care or no intervention. These benefits include increasing the uptake of immunisation in children and promoting breastfeeding, particularly in settings where breastfeeding rates are low. The review also concludes that LHWs can be effective in reducing mortality and morbidity from common childhood illnesses, including acute respiratory infections (ARI), malaria, diarrhoea, malnutrition and other illnesses during the neonatal period. The tasks undertaken by the LHWs in these studies were wide. They included educating mothers in their homes and in the community about ARI, malaria, and immunisation; distribution of de-worming tablets and vaccines; first line treatment of cases, for example with anti-malarials or antibiotics; and referral of severe cases to health facilities.

The review also suggests that LHWs can successfully support people receiving treatment for TB and achieve treatment outcomes equivalent to support delivered by professional providers. In addition to supervising and supporting TB treatment, tasks undertaken by the LHWs in these studies included the follow up of patients who had failed to adhere to treatment and referral of patients with TB-like symptoms. Other studies in the review, focusing on chronic diseases such as hypertension, suggest that here also LHWs can provide supportive care effectively.

A key question for policy-makers in low and middle income country settings is the extent to which this research evidence is applicable to their setting. Factors that need to be considered in assessing whether the effects of LHW programmes, as outlined above, are likely to be transferable to other settings include:

Whether the studies from which the evidence was drawn were conducted in similar settings to that in which the implementation decision is being taken.

Whether there are important differences in on-the-ground realities and constraints that might substantially alter the feasibility and acceptability of a LHW programme, compared to the sites in which the studies were done. For example, whether there is financial and political support for LHW programmes, including support from health professional organisations.

Whether there are important differences in health system arrangements that may mean that a LHW programme could not work in the same way as in the sites in which the studies were conducted. For example, if there is no mechanism for employing LHWs within the public health system in the implementation setting.

Whether there are there important differences in the baseline conditions between where the studies were done and the implementation setting. For example, if the incidence of TB is much lower than in the study settings, perhaps making it less cost-effective to employ LHWs to support TB patients.

The availability of routine data on who might benefit from the intervention (e.g. children whose immunisation is not up-to-date). Such data are needed to target these programmes towards the areas of greatest need.

Whether there are sufficient resources to provide ongoing clinical and managerial support for LHWs and to ensure the availability of supplies and equipment, such drugs and vaccines.

Improving access to primary health care since Alma-Ata has faltered in many countries. LHWs are one of a number of promising health systems strategies to improve the delivery and performance of primary health care in low- and middle-income settings. These programmes need to be tailored to local circumstances and health systems and, where the evidence base is weak, implemented in the context of rigorous evaluation.

Simon Lewin, Health Systems Research Unit, Medical Research Council of South Africa and Norwegian Knowledge Centre for the Health Services, Norway

Social determinants have extremely powerful influences on health. The World Health Organization’s Commission on the Social Determinants of Health worked for several years to explore the global situation further. Ruth Bell, from University College London, talks about the work of the Commission and urges health workers at community level to call for action.

Health workers, more than anyone else, see the dramatic effects of the social determinants of health in their daily work. There is no biological reason why a girl born in Zambia should have a life expectancy of 43 years, while her counterpart born in Japan should have a life expectancy twice as long at 86 years. In a deprived part of Glasgow, Scotland life expectancy for men, at 54 years, is less than the average for men in India (62 years) where nearly 80 per cent of the population live on less than two dollars a day. Social determinants are linked to ill health and premature death witnessed by health workers wherever they are around the world.

The social determinants of health are the conditions in which people are born, grow, live, work and age, and the structural drivers of those conditions, that is the distribution of power, money and resources. The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization in 2005 to support action on the social determinants of health to improve overall population health, improve the distribution of health, and to reduce disadvantage due to poor health. It published its Final Report and recommendations in 2008.

The CSDH’s aim was to stimulate action to reduce the health inequalities that exist between countries and within countries. According to the CSDH, in situations where health inequalities are preventable and avoidable, but are not avoided, they are inequitable, and taking action to reduce them is a matter of social justice.

The CSDH recommendations are based on three principles for action:

1. Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.

2. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.

3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness
about the social determinants of health.

What kind of action has the CSDH stimulated and what will be the effects on health?

It can seem a long way from a high-level policy review to action that makes a difference on the ground. Three points are important here. First, health inequities are associated with social inequalities. Health outcomes are linked to position in social hierarchies, described by income, occupation and education, by ethnic group or by gender and to geographic location, for example, rural or urban. In particular, poor health outcomes are likely where social inequalities intersect, for example, for children of women with no education in poor households in rural areas. Studies in low and middle income countries in Africa and Asia show a stepwise increase in under-five mortality across households by wealth, with children from the poorest fifth of households more likely to die before their fifth birthday than the next poorest and so on across the distribution. This pattern is seen for a number of health outcomes and is known as the social gradient in health, meaning that health outcomes are associated with people’s position in the social hierarchy. The social gradient has important implications for policy as it means that policies and programmes must not only target the worst off in society, but must also address the conditions of the whole of society in order to tackle the gradient in health.

Second, and crucial to the social determinants of health approach, is that where differential health outcomes are linked to social inequalities, then action to improve health outcomes must include action to reduce social inequalities. Seen in this light, every sector is, in effect, a health sector, because every sector, including finance, business, agriculture, trade, energy, education, employment, and welfare, impacts on health and health equity.

Thirdly, action needs to happen at global, national and local levels. The national level policy environment needs to empower grass roots community participation in identifying what needs to happen, in developing interventions and programmes and in evaluating their effects. The Commission’s report is optimistic. The global movement for health equity is growing. Progress may be patchy but progress can be made and the report contains examples of successful action including work in Sri Lanka and India (see articles in this issue of Health Exchange). But there needs to be more innovation and more evaluation so that promising approaches can be developed and extended to reach more people. Health workers at the heart of communities have a pivotal role to play in raising awareness and calling for action on social determinants and in the process of developing and evaluating action at local and national level.

The Commission on Social Determinants of Health’s Final Report and recommendations are published in: Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health, 2008, World Health Organization, available at: http://www.who.int/social_determinants/thecommission/finalreport/en/index.html

Over 700 people living in Korogocho and Viwandani slums in Nairobi, Kenya have benefited from free drugs, regular screening and check-ups for heart disease, hypertension and other chronic conditions. Not what you might expect from a research institute, but this is how the African Population and Health Research Center (APHRC) is combining research and action. Elizabeth Kahurani and Rose Oronje tell the story.

The African Population and Health Research Center (APHRC) is spearheading efforts to ease the growing burden of chronic disease, especially among the urban poor. “Diseases that affect the heart and the blood circulation system, also known as cardiovascular diseases (CVD), are a leading cause of death and ill health in sub-Saharan Africa among adults aged 30 years and above,” said Dr Catherine Kyobutungi, an Associate Research Scientist at APHRC.

Projections from WHO’s Global Burden of Disease indicate that from 1990 to 2020, the burden of CVD faced by African countries will double. The increase in the number of people diagnosed with CVD is alarming. Africa’s weak health systems, which are already collapsing under the yoke of infectious diseases, now have to contend with this glaring epidemic.

“Our health systems are ill prepared to handle the increasing burden of chronic diseases, mainly due to lack of data and poor health information systems,” explained Dr Kyobutungi, underscoring the need for research. Early diagnosis of these conditions could help prevent complications and prolong life. Regular screening could help individuals lead healthier lives as they will have more access to better information and be able to make different choices.

These diseases greatly affect the quality of life of individuals who have them. They are chronic and expensive to manage and they often strain the resources of families. In urban slums, the high stress environment, risky behaviours and limited access to health care mean poor marginalised populations in these slums are adversely affected. For this reason APHRC is combining research and action. APHRC is collaborating with the City Council of Nairobi, Provide International and The Kenya Diabetes Management and Information Center to provide free medical services to residents of Korogocho and Viwandani slums in Nairobi, Kenya. Over 700 people in these two communities have now benefited from free drugs, regular screening/check-ups, counselling and other services offered at the CVD medical clinics.

Before the project started, many of the beneficiaries carried out their day-to-day routines unaware that they suffered from diabetes or hypertension. When some people experienced constant headaches or fatigue, they thought it was normal. “I often would feel fatigued even without having engaged in any chores,” said Beatrice Wakeeni, who was among the first people to be screened. “I got a visit from two of APHRC’s field staff who I allowed to conduct a hypertension and diabetes screening. After the procedure, one of them paused and politely asked me, ‘Cucu (grandmother), have you been thinking a lot lately?’ Then they slowly explained that I was hypertensive.” The same story goes for 48-year-old John Mburu, who experienced frequent headaches but did not think that it was anything serious. When he was screened, he discovered that he had hypertension.

Previously, no-one informed the slum population of the need for regular screening. Even if they had been informed, the fee charged for screening is way beyond their means. The majority of the population survives on under a dollar a day and many take care of large families. “All of us here thank APHRC for bringing these health services close to us. Many people here suffer and die because they even do not know where to go for help,” John Mburu said.
The clinics are part of a wider research project whose main objective is to assess CVD risk factors and risk perception among the adult population in Nairobi slums. For a long time, CVD have been associated with the rich as a lifestyle disease, but current trends are proving otherwise. This research study will examine linkages between socio-economic and socio-cultural factors, as well as health behaviour that put the urban poor at risk. If taken up, this evidence-based information will no doubt inform strategies for developing sustainable health systems and other interventions that target this population effectively.

Being an international research organisation, APHRC has over the years continued to generate credible scientific evidence with an aim to promote the wellbeing of Africans through policy relevant research on population and health. The organisation runs a continuous survey that monitors households within the Korogocho and Viwandani slum areas on a regular basis. Data from this survey serves to inform policies and programmes that aim to address the challenges of an ever growing urban population, particularly now in the context of a huge economic downturn. Besides health, APHRC has conducted further research on education, poverty, and sexual and reproductive health and continues to engage actively and work with policy makers as well as other key stakeholders who use this research to bring about the much needed change.

The face of disability in South East Asia is changing. Disabled women are becoming more visible in the disability movement and getting their voices heard. Kuhu Das, a disabled woman activist and Director of the Association of Women with Disabilities (AWWD) in India tells of her struggle and how a unique project is training disabled women to be new leaders.

I had polio in early childhood causing impairment in my mobility, so I am disabled. When I started working for the empowerment of women in general, I realised that empowerment programmes did not include disabled women. At every forum I would bring up issues around disability but I was the only person talking about it. Hardly any disabled women would come out and talk about themselves and their rights.

So I decided to work for the empowerment of disabled women. I started an organisation in 2002 called the Association for Women with Disabilities (AWWD). Through all this activity, I became a leader over time; not part of my plan, but it happened that way.

Disabled women in India face huge discrimination: as a woman experiencing gender discrimination and as a disabled person experiencing prejudices around ‘difference in abilities’. Disabled girls and women struggle to access rights to education, health, employment and others. They often have low self esteem, low levels of literacy and experience discrimination by their own families. Disabled girls and women living in rural areas are more deprived than those in urban areas as there are few support services, and gender-biased cultural practices are more common. This creates further barriers for disabled women to exercise their rights.

At AWWD we analysed the root of the marginalisation of disabled women. We saw that they are often invisible and unable to voice their discrimination. This is made worse by a lack of leadership among, and by, themselves. A situational analysis reflected the need for more disabled women leaders. So we started work to address this and gave birth to the project Creating spaces for Women with Disabilities to Communicate and Advocate for their rights. The project is really unique as we do not provide any kind of rehabilitation service or assistive appliances such as wheelchairs. We focus on supporting disabled women to be leaders and advocate for their rights. The disability rights movement is strong in India, but there is still gender discrimination within it. Policies, programmes and benefits have mostly brought changes into the lives of disabled men. It has not changed the lives of disabled women significantly. We need disabled women to be leaders to ensure their prominence in the movement for disabled people’s rights.

The project is regional. Core partners are Association of Women with Disabilities (AKASA) in Sri Lanka, Social Assistance and Rehabilitation for the Socially Vulnerable (SARPV) in Bangladesh and AWWD in India. We recognised the lack of evidence-based data and information about disabled women’s situations, attitudes of policy makers, and the shortcomings of disability projects run by governments and NGOs. Each partner carried out a base-line survey in their country. A study also gathered regional evidence in Nepal under the guidance of AWWD. Based on findings, we planned leadership training to create more disabled women leaders at regional, national and grass-root levels. Healthlink Worldwide in the UK provided technical support and guidance to design modules, develop materials and conduct leadership trainings to all the core partners.

The training prompts disabled women to think about leadership. Who is a leader? What kind of leader do you want to be? How can you be a good leader to influence other disabled women? How do power relationships, discrimination and marginalisation affect disabled women at all levels from the family to the wider community and nationally? How can you influence policy-makers and what is a good advocacy strategy? What is the existing international legislation for the protection of the rights of disabled people, and women specifically?

We conducted regional leadership training and 25 disabled women participated from South Asian countries. We then held national trainings in the three core countries – India, Bangladesh and Sri Lanka – for over 75 disabled women. We are conducting similar national level training in the other countries involved in the project, and training in Pakistan, Afghanistan, Nepal and Bhutan is already planned for this year.

After the training, disabled women were highly motivated to take action and become more visible. They became more confident and better organised. Now when they have advocacy meetings with government representatives they talk with greater boldness and strategic intention.In India, Sri Lanka and Bangladesh, the governments know there are disabled women trying to get their voices heard.

New leaders are already in action. Rupa in India has started her own initiative to organise disabled women in her district, transfer her leadership skills and advocate for their rights. Nishintha in Sri Lanka started organising disabled women and is preparing to conduct leadership training at district level. In each country disabled women have formed networks to build nationwide movement and advocacy.

Across the region disabled women are communicating, sharing and disseminating information about their new initiatives to the global community. A network website – Network of South Asian Women With Disabilities (NSAWWD) has been set up, which is a good resource on disabled women’s issues. To continue the work, we want to provide seed grants to support these new leaders create a stronger movement, but currently the project’s support is limited and we need extra resources to do that.

In South East Asia, largely because of this initiative, disabled women are starting to understand that their rights cannot be claimed by anyone else. They are coming forward, speaking for themselves and showing strong leadership to other disabled women. I hope that every region can have a movement of disabled women and that we can link up in the future.

Kuhu Das is the founder and Director of the Association for Women with Disabilities, India kuhudas@awwdindia.org
Association for Women with Disabilities (AWWD)

David Curtis is Head of Programme and Capacity Development at Healthlink Worldwide Curtis.d@healthlink.org.uk

Female condom stand at the International Conference on AIDS and STIs in Africa (ICASA) 2008 Photo: Ilze Smit

Female condom use could vastly reduce the number of unwanted pregnancies and sexually transmitted diseases, including HIV. So what’s stopping women from using them? Lucie van Mens, of the Universal Access to Female Condom Joint Programme and Ilze Smit, of the World Population Foundation, consider the issues.

The female condom has been around for fifteen years. Today it is the only female-initiated prevention method that provides double protection – against pregnancy and disease. Yet the female condom is still not widely promoted or used. In a world where 200 million women have no access to contraceptives and one third of all pregnancies are unintended (and many unwanted) this is unacceptable. In sub-Saharan Africa where 61per cent of all new HIV infections are among women, this is indefensible.

Female condoms have several advantages over the male condom. Firstly women are in control over when they use them. The use of male condoms often has to be negotiated by women over and over again and relies on the cooperation of men. Female condoms have to be negotiated only once. If partners agree, women can simply apply the female condom to themselves every time they have sex. They can be inserted several hours before the sexual act takes place, and foreplay does not need to be interrupted.

The female condom is also highly acceptable to people. UNAIDS and WHO published a report in 1997 called The Female Condom: An Information Pack. Forty one studies of the female condom showed acceptance levels ranging from 41 per cent-95 per cent. In 2006 another study by Vijayakumar et al reviewed 60 acceptability studies and concluded that research on the female condom should move away from assessing acceptability. In other words, most people find the female condom acceptable to use.

In spite of its advantages and good characteristics, the female condom has been neglected as a reliable prevention method. This might be for a variety of reasons. The product suffers from a bad image, but so did male condoms when they first came onto the market, so there is a need to present the product in a positive light, with good marketing and appealing packaging. There is also currently a lack of variety in female condoms. The best known types are FC1 and FC2 made by the Female Health Company. The FC1 and FC2 are similar in shape and have both an inner and outer ring. The main difference is that FC1 is made of polyurethane, which can produce a ‘crispy’ noise. The FC2 is made of nitrile, a ‘silent’ fabric. The production process for the FC2 is also cheaper, making it a better product.

In order for women to have the choice to use female condoms, supply chains need to function well. Female condom programmes implemented up until now tend to run out of stock quickly after, or sometimes during, programmes. If women cannot rely on the availability of the product at the time they need it, they will lose interest. There should be more choice of products so that women can get the female condom that suits them, that fits best, and that they personally find easiest to use. More female condoms need to be available on the market. However any new health product needs to meet the quality control standards set up by the World Health Organization, a complex and costly process.

The Female Health Company’s condoms are the only products to have obtained this status and this has led to a near monopoly of the market. Finally, the cost of the female condom is currently too high. The procurement price for the female condom is up to 15 times higher than the male condom. This is partly because of the current limited market for female condoms, so increasing demand will inevitably bring down the price.

It is estimated that around 10 million Euros are needed for the development of a new low-cost female condom. This is a lot of money, but compared to investments in prevention methods such as microbicides and vaccines, the investment is relatively low.

Meanwhile, although new products are needed, there are still things we can do as donors and agencies to promote the use of female condoms in women’s sexual and reproductive health programming.

Lucie van Mens is coordinator of the Universal Access to Female Condom (UAFC) Joint Programme, employed at Oxfam Novib and Ilze Smit is advocacy officer of the UAFC Joint Programme at the World Population Foundation (WPF).